Colostomy (sigmoidostomy), loop, laparoscopic construction

Ideally, the stoma should be marked and the subsequent instructions for stoma care given by specially trained enterostomal therapists or an experienced surgeon.

Tips:

• Trial marking, with the patient supine or already sitting, within the left rectus abdominis (level of the umbilicus) in a 10×10cm skin area, preferably without folds and creases, scars and bony prominences.
• Check of the planned site with the patient in motion (standing, stooping down).
• The selected  site should be easily accessible to the patient and within his/her visual field and away from the natural beltline.
• To allow for intraoperative complications marking a secondary location is recommended.
• Dressing the markings with sensitive skin bandages.
• The site of the ileostomy deeply affects its management and thus the patient’s quality of life!

For establishing the pneumoperitoneum, a supraumbilical skin incision is generally recommended. Dissect down to the fascia with scissors and bluntly split with Langenbeck retractors.

Establish the pneumoperitoneum via a Veress needle after aspiration, flush and drop testing. To prevent the Veress needle from puncturing the bowel, elevate the fascia with a Backhaus towel clamp. Alternatively, access via minilaparotomy (e.g., after previous surgery) may be advisable.

After establishing the pneumoperitoneum with an intraabdominal pressure of 11–14mmHg remove the cannula and insert the 10mm trocar for the laparoscope. Advance the laparoscope through this trocar into the abdominal cavity.

After a 360° check and inspection for pathologies such as adhesions, lesions, etc., insert both 5mm working trocars under view and transillumination (caution: epigastric vessels) in the right lower quadrant and mid-abdomen respectively.

Grasp the colon segment (here: sigmoid) and pull it mediad. Now divide the peritoneal adhesions and dissect the descending colon down to the Gerota fascia. Carefully respect the ureter.

Comment: 

• When performing end colostomy, free the bowel and then close and divide it with an EndoGIA stapler. This then requires adequate mobilization of the proximal limb.